Determination of the refractive index and thickness of a hydroxide-catalysis bond between fused silica from reflectivity measurements

Hydroxide-catalysis bonding is a high precision jointing technique producing strong, transparent and thin bonds, the use of which in the delicate fused silica mirror suspensions of aLIGO have been instrumental in the first detections of gravitational radiation. More sensitive future gravitational wave detectors will require more accurate (ideally in situ) measurements of properties such as bond thickness. Here a non-destructive technique is presented in which the thickness and refractive index of a bond are determined from measurements of optical reflectivity. The reflectivity of a bond made between two fused silica discs using sodium silicate solution is less than 1⋅10^-3 after 3 months. The thickness decreases to a constant value of around 140 nm at its minimum and the refractive index increases from 1.36 to 1.45. This proves that as well as determination of bond thickness in situ this bonding technique is highly interesting for optical applications.

Spatiotemporal accuracy of real-time 3D echocardiography in the neonatal and pediatric setting--validation studies using small dynamic test objects

The precision of real-time 3D-echocardiography (RT3DE) is not sufficiently validated for small, fast-moving structures such as the neonatal and pediatric heart.

PURPOSE

To assess the spatiotemporal accuracy of RT3DE in small, moving test objects.

MATERIALS AND METHODS

Small, calibrated test objects in the size of neonatal and pediatric heart chambers were made from polyurethane foam or metal wire mesh and moved in a water bath through a calibrated dynamic test system. Using matrix transducers (X7-2, ie33 and X4-1, Sonos 7500, Philips, Andover, USA), 2 D and live 3 D datasets under variation of the motion speed (0.033 - 0.133 m/s corresponding to 50 - 200 heart cycles/minute), the volume rate and transducer position were recorded and analyzed (QLab 7.0, Philips).

RESULTS

3 D datasets of the moving test objects showed relevant spatial distortion, which was obviously related to the sequential scanning technology of the matrix transducer. Different segments of a test object were not recorded simultaneously, but rather row-by-row, so that there was a time delay between the first and the last-recorded voxel of a single 3 D volume (mean±SD: 28.9 ± 7.82 m/s or 80 ± 7 % of the time duration of a 3 D volume). With increasing motion speed of the test object and reduced 3 D volume rate, the distortion artifacts increased significantly.

CONCLUSION

3 D acquisitions using matrix technology demonstrate relevant spatiotemporal inaccuracies. This may lead to misinterpretations during the evaluation of the synchronicity of valvular or ventricular motion and incorrect definition of volume estimations. In particular, at higher heart rates and higher rates of movement, these limitations have to be taken into account in clinical practice.

Prototype of an auto-calibrating, context-aware, hybrid brain-computer interface

We present the prototype of a context-aware framework that allows users to control smart home devices and to access internet services via a Hybrid BCI system of an auto-calibrating sensorimotor rhythm (SMR) based BCI and another assistive device (Integra Mouse mouth joystick). While there is extensive literature that describes the merit of Hybrid BCIs, auto-calibrating and co-adaptive ERD BCI training paradigms, specialized BCI user interfaces, context-awareness and smart home control, there is up to now, no system that includes all these concepts in one integrated easy-to-use framework that can truly benefit individuals with severe functional disabilities by increasing independence and social inclusion. Here we integrate all these technologies in a prototype framework that does not require expert knowledge or excess time for calibration. In a first pilot-study, 3 healthy volunteers successfully operated the system using input signals from an ERD BCI and an Integra Mouse and reached average positive predictive values (PPV) of 72 and 98% respectively. Based on what we learned here we are planning to improve the system for a test with a larger number of healthy volunteers so we can soon bring the system to benefit individuals with severe functional disability.

Impact of Newly Available Drugs on Clinical Progression in Patients with Virological Failure after Exposure to Three Classes of Antiretrovirals

Objective

To study the prognosis of HIV-infected patients with virological failure after exposure to three classes of antiretroviral drugs (ARVs).

Design

Cohort study. Setting: French Hospital Database on HIV.

Patients

Patients previously exposed to at least two nucleoside reverse transcriptase inhibitors (NRTIs), two protease inhibitors and one non-NRTI, with viral load (VL) values of >5000 copies/ml after the exposure criteria were met and a new treatment initiated between 1998 and 2001 with VL >5000 copies/ml.

Main outcome measures

Risk of new AIDS-defining-events (ADEs) or death from first introduction of a drug never used before occurring between 1998 and 2001 defined as baseline.

Results

The main baseline characteristics of the 1092 patients were: previous ADE in 49% of cases, median CD4 cell count 181 μl, median VL 4.9 log10 copies/ml, median duration of ARV therapy 5.0 years and previous exposure to a median of nine ARVs. The crude progression rates were 20.1/100 patient-years among patients included in 1998, 15.1 in 1999, 11.1 in 2000 and 8.6 in 2001. After adjustment for baseline characteristics, the calendar year of inclusion was associated with the risk of clinical progression ( P<0.001). When the types of newly available drugs used at baseline or during follow-up were introduced into the model, year of inclusion was no longer associated with the risk of clinical progression ( P=0.42), while exposure to amprenavir/r, lopinavir/r, abacavir or tenofovir was associated with a lower risk.

Conclusions

The clinical prognosis of heavily pretreated patients experiencing virological failure improved between 1998 and 2001, mainly thanks to the use of newly available drugs with more favourable resistance profiles.

Facteurs de risque de syndrome d'hypersensibilité à l'Abacavir en pratique clinique de routine

Abacavir (ABC) is a generally well-tolerated NRTI. However, up to 5% of patients may develop hypersensitivity syndrome (HSS) within the first weeks of treatment. The objectives of this study were to describe the side effects of ABC, to evaluate the incidence of the ABC-HSS, and to identify the risk factors of HSS after first exposure to ABC in a cohort of patients followed up in a university HIV clinic.

METHODS

The charts of all HIV-infected patients who started ABC between February 1998 and May 2002 were reviewed. HSS was defined as the onset, within 8 weeks of ABC initiation, of either a skin rash associated with at least one of the following symptoms (fever, gastrointestinal symptoms, respiratory symptoms, myalgia, malaise) or at least three of the above symptoms in the absence of rash. A multivariate logistic regression analysis was performed to identify risk factors of HSS.

RESULTS

Of the 191 patients studied (134 M, 57 F, mean age 39 years), 53 (27.8%) presented with manifestations that were regarded as potential side-effects of ABC. Ten (5.2%) developed HSS, none of whom died. Two factors were independently associated with an increased risk of HSS: history of allergy to nevirapine (OR 8.1, 95% CI 1.6-40.5, p = 0.02), and being naïve to ART (OR 5.8, 95% CI 1.2-28.5, p = 0.04).

CONCLUSION

This study "in the real world" confirms that the incidence of ABC-induced HSS is of about 5%. It also confirms that HSS occurs more frequently in patients with a history of allergy to nevirapine and in ART-naïve patients.

Triple Nucleoside Combination Zidovudine/Lamivudine/Abacavir versus Zidovudine/Lamivudine/Nelfinavir as First-Line Therapy in HIV-1-Infected Adults: A Randomized Trial

Objective

To compare the efficacy and safety of a triple nucleoside combination to a protease inhibitor-containing triple regimen as first-line antiretroviral therapy (ART) in HIV-1-infected patients.

Design

Open-label study in HIV-1-infected ART-naive adults, randomized to receive either Combivir® (lamivudine 150 mg/zidovudine 300 mg twice daily) + abacavir (300 mg twice daily), or Combivir® + nelfinavir (750 mg every 8 h) for 48 weeks. Plasma HIV-1 RNA, CD4 cell count and adverse events were assessed at baseline and weeks 4, 8, 16, 24, 32, 40 and 48.

Results

195 subjects (131 men, 64 women), median age 34 years, were randomized: 98 received combivir/abacavir and 97 combivir/nelfinavir. Baseline median plasma HIV-1 RNA was 4.2 log10 copies/ml [Interquartile range (IQR): 3.7-4.5.2] and 4.1 log10 copies/ml (IQR: 3.8–4.6), respectively. Baseline median CD4 cell count was 387 cells/mm3 (IQR: 194–501) and 449 cells/mm3 (IQR: 334–605), respectively. Nine patients (3 vs 6, respectively) did not start treatment or did not have any available efficacy data. At week 48, using the intent to treat analysis (switch/missing equals failure), plasma HIV-1 RNA was <50 copies/ml in 54/95 (57%) and 53/91 (58%) of subjects, respectively. Median CD4 increase was +110 and +120 cells/mm3, respectively. Possible hypersensitivity reactions to abacavir were reported in four subjects (4%).

Conclusion

The triple nucleoside combination combivir/abacavir is well tolerated as a first-line ART regimen in HIV-1-infected adults, with comparable antiviral activity to a nelfinavir-containing regimen at week 48.

[Medicamentous kidney protection in type 2 diabetic patients--is cheaper also more economical? A model calculation for Swiss health care]

Impaired renal function occurs in about 50% of patients suffering from type 2 diabetes, and diabetic nephropathy has become the leading cause of endstage renal disease. Reduction of blood pressure to levels around 120/80 mmHg is one of the most effective way to slow progression of diabetic nephropathy. Recent meta-analyses, however, have emphasized on the fact that ACE inhibitors (ACEI) and non-dihydropyridine calcium channel blockers (NDHP-CCB) exert nephro-protective effects which go beyond the effect of blood pressure reduction. This has lately been confirmed by a prospective trial in comparison to the betablocker atenolol. Based on these data, demographics of the Swiss population, literature data on mortality rates of type 2 diabetics with impaired renal function and studies on true costs of antihypertensives, we calculated the costs of a longterm intervention (20 years) with antihypertensives in 3536 middle-aged Swiss patients with type 2 diabetes and macro-albuminuria whose antihypertensive regimen was based either on the ACEI lisinopril, or the ND-HP-CCB verapamil, or the betablocker atenolol. Under atenolol, acquisition costs were lowest, whereas faster loss of renal function over time increased mortality rate and thus reduced the number of patients to be treated. Nevertheless, due to the fact that patients reached uremia and had to be dialyzed, 20 years of atenolol-based regimen with costs of 316 millions of Swiss francs turned out to be much more expensive than the lisinopril- or the verapamil-based regimen with 121 and 38 millions of Swiss francs, respectively. Thus, low acquisition cost is not necessarily the only important determinant of overall costs of drug therapy.

[Gastrointestinal stromal tumors in our practice]

The classification of tumours originating from the wall of gastrointestinal organs changed dramatically since of electronmicroscopy and immunohystochemistry were introduced. Previously these tumours were classified as leiomyomas, leiomyosarcomas or schwannomas. With the new methods these disorders can be described in more details and unified, and so the change to provide correct prognosis improved. Still, there are some unanswered questions remaining for the pathologists. In our material in the past 5 year we treated 9 patients because of GIST. Most of them were found in the stomach (6), one developed in the oesophagus, one in the small bowel and another one in the rectum. With describe our patients and look at the related articles literature about this important diseases. Though the incidence is under 1% of patients operated on because of gastrointestinal diseases, we would like to share our experiences in treatment.

[Flesh-eating bacteria infection of an immunocompromised patient]

After years of steadily declining morbidity and mortality due to group A streptococcal infections, a resurgence of severe, invasive disease has been ongoing since 1980, leading to the recognition of streptococcal shock syndrome (STSS), necrotizing fasciitis, the most severe form of invasive infection. The patients suffer from rapid local deep soft tissue destruction, severe septic shock and multi organ failure. The increased incidence of these infections has been accompanied by remarkable vigor in virulence and severity of the disease. The reason for this impressive change in the epidemiology and clinical manifestation of group A streptococcal infections remains unknown. The possible etiological factor is changing in virulence factor or the lack of protective immunity of the population (immunocompromise) against the invasive strains. We describe a severe necrotizing fasciitis of a 41-year-old previously immunocompromised woman. The patient developed severe septic shock, multi organ failure and perineal and lower abdominal skin, fat and fascia necrosis due to mixed GAS (aerob, anaerob) infection of the perineum and the Bartholini glands. After an aggressive surgical debridement, antibiotic and supportive therapy the generalised and local infection was treated.

Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock

STUDY OBJECTIVE

To investigate whether the respiratory changes in peak velocity (Vpeak) of aortic blood flow could be related to the effects of volume expansion on cardiac index.

DESIGN

Prospective clinical study.

SETTING

Medical ICUs of a university hospital (20 beds) and of a nonuniversity hospital (15 beds).

PATIENTS

Nineteen sedated septic shock patients who were receiving mechanical ventilation and who had preserved left ventricular (LV) systolic function.

INTERVENTION

Volume expansion.

MEASUREMENTS AND RESULTS

Analysis of aortic blood flow by transesophageal echocardiography allowed beat-to-beat measurement of Vpeak before and after volume expansion. Maximum values of Vpeak (Vpeakmax) and minimum values of Vpeak (Vpeakmin) were determined over one respiratory cycle. The respiratory changes in Vpeak (Delta Vpeak) were calculated as the difference between Vpeakmax and Vpeakmin divided by the mean of the two values and were expressed as a percentage. The indexed LV end-diastolic area (EDAI) and cardiac index were obtained at the end of the expiratory period. The volume expansion-induced increase in cardiac index was > or = 15% in 10 patients (responders) and < 15% in 9 patients (nonresponders). Before volume expansion, Delta Vpeak was higher in responders than in nonresponders (20 +/- 6% vs 10 +/- 3%; p < 0.01), while EDAI was not significantly different between the two groups (9.7 +/- 3.7 vs 9.7 +/- 2.4 cm(2)/m(2)). Before volume expansion, a Delta Vpeak threshold value of 12% allowed discrimination between responders and nonresponders with a sensitivity of 100% and a specificity of 89%. Volume expansion-induced changes in cardiac index closely correlated with the Delta Vpeak before volume expansion (r(2) = 0.83; p < 0.001).

CONCLUSION

Analysis of respiratory changes in aortic blood velocity is an accurate method for predicting the hemodynamic effects of volume expansion in septic shock patients receiving mechanical ventilation who have preserved LV systolic function.

Effect of extrusion on isoflavone content and antiproliferative bioactivity of soy/corn mixtures

The present studies were conducted to determine changes in the quantities of select isoflavones and in the bioactivity (ability to inhibit proliferation of human breast cancer cell lines) of extracts from blends of soy protein and cornmeal during extrusion processing. The extrusion of samples resulted in an average 24% decrease in the concentration of total isoflavones for all samples. Although the amounts of specific genistein-derived and daidzein-derived forms changed following extrusion, the content of the aglycones genistein and daidzein per g sample generally did not change. The extrusion of samples generally resulted in decreased antiproliferative action toward breast cancer cells, although antiproliferative activity was not eliminated. Therefore, extrusion of soy protein/cornmeal-containing foods are likely to retain a considerable portion of their isoflavone content and some of the health benefits associated with soy.

Isolated massive pleural effusion caused by pancreatico-pleural fistula

BACKGROUND

Massive pleural effusions are uncommon but well-documented complications of chronic pancreatitis, usually caused by the development of a pancreaticopleural fistula. The mechanism of the fistula formation is thought to be rupture of the pancreatic duct or pseudocyst.

MATERIAL AND METHODS

In the past 7 years we have treated 5 patients with massive pleural effusion of pancreatic origin in the Surgical Department of Semmelweis University Medical School. 4 patients were males; the average age was 52 years (range: 46-59 years).

RESULTS

All 5 patients had a history of alcohol abuse and were admitted to the pulmonary department because of respiratory distress. Other symptoms such as abdominal pain, chest pain, or weight loss were not always present. The diagnosis was confirmed by a markedly elevated amylase level in the aspirated pleural fluid. Abdominal ultrasound, CT scan, and ERCP examinations were carried out in order to determine the cause of the pancreaticopleural fistula. Conservative (nonsurgical) treatment was effective within 3 weeks in only one case. The other 4 patients required surgical management. In 3 cases distal pancreatic resection with splenectomy and cholecystectomy was done. In one case cystojejunostomy was performed. All 5 patients have been cured with complete resolution of their pleural effusions.

CONCLUSIONS

Patients with large pleural effusions may have underlying pancreatitis with a pancreaticopleural fistula. It is important to establish this diagnosis because treatment may require operative interventions.

Stability of isoflavones during extrusion processing of corn/soy mixture

The influence of extrusion processing in the presence of corn on the quantity and quality of genistein, daidzein, and their respective beta-glucoside, acetyl glucoside, and malonyl glucoside derivatives was evaluated. Products of 100% soy (textured) and a blend of 20% soy protein concentrate (SPC) and 80% corn meal (direct-expanded) were extruded, with evaluations before and after extrusion. In addition, a 3 x (3 x 3) split-plot factorial experiment investigated the influence of barrel temperature (110, 130, 150 degrees C), moisture content (22, 24, 26%), and relative residence time (1, 0.8, 0.6) on extruder response and isoflavone profile. The extrusion barrel temperature had the most influence on isoflavone profile, especially decarboxylation of the malonyl beta-glucoside, followed by the moisture content. The amount of extractable isoflavones decreased after extrusion for both the SPC and SPC/corn meal blend when extracted with 80% aqueous methanol but remained approximately the same when first hydrated with water before extraction. However, initially hydrating with water produced enzymatic glycolysis in the unextruded samples, increasing the aglycons dramatically.

[Abdominal trans-sphincter resection of the anus: new possibilities in the surgical management of deep rectal cancer, with preservation of the anal sphincter]

The last decade has brought marked changes in the surgical treatment of rectal cancer: as the indication of the sphincter-saving procedures was extended, the rate of the abdomino-perineal excision has decreased even in the case of tumours of the distal third of the rectum. However, even with the use of the modern stapling devices, the anterior resection and colo-anal anastomosis may not always be feasible by the traditional abdominal approach. In these cases the sphincter-saving resection can be performed by a particular approach, the abdomino-transsphincteric technique. The authors present this seldom used operation. From the 1-st of January 1994 to the 31-st of August 1996 14 abdomino-transsphincteric resections have been performed. The mean age of the patients was 62.2 (38-81) years. The lower edge of the tumours was situated at 6.3 (5-8) cm from the anal verge. The anastomosis was performed by the double stapling technique in 8 and by hand suture in 6 cases, its distance from the anal verge was 3.2 (3-4) cm. A colon J-pouch was used in 3 cases and a diverting colostomy was performed routinely. One patient died in the postoperative period and a reoperation (abdomino-perineal excission) was performed because of left colon necrosis: Anastomotic leakage was observed in one case. By the time of the present study, 11 patients have had their colostomies closed. The continence is acceptable in every case and all the patients experience a better subjective quality of life, than it was while wearing the colostomy. The use of this technique has helped to avoid a permanent colostomy in 21 out of 33 cases operated on for cancer of the distal rectal third in the reviewed period.

[New approach to the management of gastrointestinal tumor]

The author summarizes the changes recently developed in the treatment of gastrointestinal tumors. He gives a detail analysis of stages of malignant diseases as well as he demonstrates the newest opinion about the lymphadenectomy, tumor resection, and new therapy modalities of liver metastases.

The use of modified Baylor score in the prediction of rebleeding in peptic ulcer hemorrhage

The upper gastrointestinal bleeding is still an everyday problem. 40-50% of these bleedings are originating from peptic ulcer. The rate of rebleeding after initial hemostasis is 30-50%. In this group of patients we can observe the highest morbidity and mortality. The aim of this work is to select those patients who belong to the high risk group from the point of rebleeding. For this purpose we introduced after a retrospective analysis the modified Baylor score. In this scoring system the age, the number and severity of parallel illnesses, the hemostatus by the admittance, the ulcer size and location and the stigmata of recent hemorrhage are taken into consideration. On the basis of this every patient gets a score between 0 and 31. Based on our retrospective analysis we could establish three grades of risk groups: low risk (0-7), middle risk (8-11) and high risk (12 and over). In the low risk group there was no rebleeding. In the middle risk group we observed 4 rebleedings in 19 patients, while in the high risk group there were 32 rebleedings out of 36 cases. As a conclusion we can state, that the modified Baylor score is capable for the selection of high risk patients for rebleeding. With the early elective operations in these cases the high morbidity and mortality can be reduced.

[Simultaneous occurrence and treatment of right atrial myxoma and extensive colonic polyposis causing recurrent intestinal hemorrhages]

The authors describe the case history of 68 year old man. Right atrial myxoma had been diagnosed two years prior to this present observation, however surgical intervention has been contraindicated due to high operative risk. Later the patient was referred to a cardiological evaluation because of chronic atrial fibrillation before a cataract surgery in a symptom free condition. The right atrial myxoma caused inflow obstruction and tricuspid regurgitation was removed before the eye surgery. In addition, tricuspid valve replacement and revascularization of three coronary arteries has been performed. The patient receiving chronic anticoagulant therapy experienced severe gastrointestinal bleeding the source of which turned out to be a partially malignant colon polyposis. The polyps were successfully removed by coloscopy and intra operative coloscopy. No gastrointestinal bleeding has been observed afterwards in spite of the continued anticoagulation. After review of the literature the authors observed that according to their knowledge the common occurrence of the right atrial myxoma and the colon polyposis had not been described before.

Surgery for esophageal and cardia cancer in Hungary: a nationwide retrospective five-year survey

A nationwide retrospective 5-year survey was conducted, examining the surgical treatment of cancer of the esophagus and the esophagogastric junction in Hungary. The population of Hungary is at low risk of developing esophageal cancer, with an associated mortality rate of 5.84 per 100,000 in 1992. During the 5 years between 1988 and 1992, a total of 1197 resections were performed for cancer of the esophagus and cardia, with 817 for esophageal cancer (in the cervical area in 40, the upper and midthoracic areas in 436, and the lower third in 341), and 380 for cancer of the cardia. Most of the procedures were total or subtotal esophagectomy, performed in 629 patients, with the stomach being used for replacement of the esophagus in 555 (88.2%) patients, the right colon in 46 (7.3%) and the left colon in 28 (4.5%). Transhiatal blunt esophagectomy was performed in 264 patients, representing 22.0% of all resections. The overall leakage rate was 21%, occurring in 251 patients, and the overall mortality rate was 13.5%, or 162 patients. A very strong correlation existed between the experience of the departments where surgery was performed and the mortality rate.

The relationship between portal venous and hepatic arterial blood flow. I. Experimental liver transplantation

The relationship between the changes in portal venous and hepatic arterial blood flows, in the liver is a much disputed question, it has tremendous significance in the practice of transplantation, and an explanation has been available since 1981, when Lautt published the so-called "adenosine washout theory". According to our earlier observations the decrease of portal pressure or flow consistently led to an increase in hepatic artery flow. At the same time changes in hepatic artery flow or pressure seemed to produce only inconsistent effects on the portal circulation. In the present experiments liver transplantation (OLTX) was carried out on mongrel dogs by Starzl's method. Electromagnetic flow probes were placed on the hepatic artery and the portal vein before removal of recipient's liver, and after completion of all vascular anastomoses to the newly inserted liver, during the recirculatory phase of OLTX. The flow probes were connected to a Hellige electromagnetic flowmeter, portal venous and systemic arterial pressures were also recorded. The control HAF was 241 +/- 23 ml/min, the average PVF was 517 +/- 47 ml/min before removal of the recipient's liver. In the recirculatory phase of HAF increased, by 71 +/- 12% (p < 0.001). The PVF decreased in most animals after OLTX. The decrease was in average -40.2 +/- 3.5% (p < 0.001). The THBF calculated by adding the HAF and PVF showed a small, but not significant decrease recirculation. The systemic arterial pressure decreased slightly and portal vein pressure rose in most animals after OLTX. There was a substantial increase in portal inflow resistance and prehepatic arteriolar resistance and a decrease in hepatic artery resistance. The decrease of PVF after OLTX can be explained by progressive fluid accumulation in the liver parenchyma and increased sinusoidal and portal inflow resistance. The prolonged and continuous increase in hepatic artery flow during the recirculatory phase of OLTX may be due to the decrease of portal flow. The exact mechanism, by which a change in portal flow leads to arteriolar dilatation, can be most probably explained by the "adenosine washout theory" of Lautt.

A new method to measure portal venous and hepatic arterial blood flow in patients intraoperatively

The intraoperative measurement of the afferent circulation of the liver, namely the hepatic artery flow and portal venous flow was carried out upon 14 anesthetized patients having carcinoma in the splanchnic area, mainly in the head of the pancreas by means of transit time ultrasonic volume flowmeter. The hepatic artery flow, portal venous flow and total hepatic flow were 0.377 +/- 0.10; 0.614 +/- 0.21; 0.992 +/- 0.276 l/min respectively. The ratio of hepatic arterial flow to portal venous flow was 0.66 +/- 0.259. There was a sharp, significant increase in hepatic arterial flow (29.8 +/- 6.1%, p < 0.01) after the temporary occlusion of the portal vein, while the temporary occlusion of hepatic artery did not have any significant effect on portal venous circulation. The interaction between hepatic arterial flow and portal venous flow is a much disputed question, but according to the presented data here, it is unquestionable, that the decrease of portal venous flow immediately results a significant increase in hepatic artery circulation.

Changes in hepatic hemodynamics due to primary liver tumours

Data regarding the afferent circulation of the liver in patients with primary hepatocellular carcinoma are controversial, we have carried out measurement of hepatic arterial and portal venous flow intraoperatively by transit time ultrasonic volume flowmetry. In patients with primary hepatocellular carcinoma the hepatic artery flow increased to 0.55 +/- 0.211 compared with the control value of 0.37 +/- 0.102 1/min. (p < 0.01). The portal venous flow decreased from 0.61 +/- 0.212 l/min. to 0.47 +/- l/min. P < 0.01). Due to the opposite changes in the afferent circulation the total hepatic blood flow did not change significantly, compared with controls. The ratio of hepatic arterial flow to portal vein flow increased to 1.239 +/- 0.246 in patients with hepatocellular carcinoma, which is double of the control value (0.66 +/- 0.259 l/min). After resection this ratio did not change. The resection did not alter hepatic artery or portal venous flow significantly, although the total hepatic blood flow decreased significantly (p < 0.01). On the basis of our early results it is possible that the ratio of the two circulations may be to deel measured with doppler ultrasound and provide diagnostic information.

The afferent circulation of the liver in patients with primary hepatocellular carcinoma

BACKGROUND/AIMS

The data on the afferent circulation of the liver, in patients with primary hepatocellular carcinoma, are controversial or non-existent.

MATERIALS AND METHODS

The authors measured hepatic arterial and portal venous flow intra-operatively by transit time ultrasonic volume flowmetry.

RESULTS

In patients with primary hepatocellular carcinoma, the hepatic artery flow increased to 0.55 +/- 0.21 l, as compared with the control value of 0.37 +/- 102 l/min (p < 0.01). The portal venous flow decreased from 0.61 +/- 0.212 l/min to 0.47 +/- 0.203 l/min p < 0.01). Owing to the opposite changes in the afferent circulation, the total hepatic blood flow did not change significantly. The ratio of hepatic arterial flow to portal vein flow increased to 1.239 +/- 0.246 in patients with hepatocellular carcinoma, which is twice the basic control value (0.66 +/- 0.259 l/min). After resection, this ratio showed virtually no change. The surgical intervention, that is resection of the liver, did not significantly alter hepatic artery and portal venous flow, although total hepatic blood flow decreased significantly (p < 0.01). The pronounced increase in the ratio of hepatic arterial flow may be attributed to the decrease in portal venous flow caused by the primary hepatocellular carcinoma. The decrease in venous flow can most probably be explained by compression and infiltration of the intrahepatic branches of the portal vein. As we pointed out, the decrease in portal venous circulation leads to an increase in hepatic arterial flow.

CONCLUSIONS

On the basis of our initial results, it seems probable that the ratio of the two circulations represents a diagnostic tool for the altered circulation in patients with hepatocellular carcinoma. The significance of this phenomena is not yet quite clear, but a review of the literature shows that similar observations have not been reported. In practical terms this phenomenon may be useful from the point of view of US and Doppler US diagnosis, e.g. in the case of a hypo-echoic or hyperechoir, mass in the liver, increased blood flow in the hepatic, artery, and decreased portal venous flow, a malignant liver tumor is virtually certain. The authors hypothesise that any pathology in the liver may lead to a primary decrease in PVF and a subsequent increase in HAF.

The interaction between hepatic arterial and portal venous blood flows; simultaneous measurement by transit time ultrasonic volume flowmetry

Intra-operative measurement of the afferent circulation of the liver, namely hepatic artery and portal venous flow was carried out in 14 anesthetized patients with carcinoma of the splanchnic area, mainly in the head of the pancreas, by means of transit time ultrasonic volume flowmetry. The hepatic artery flow, portal venous flow and total hepatic flow were 0.377 +/- 0.10; 0.614 +/- 0.21; 0.992 +/- 0.2761/min, respectively. The ratio of hepatic arterial flow to portal venous flow was 0.66 +/- 0.259. There was a sharp, significant increase in hepatic arterial flow (29.8 +/- 6.1%, p < 0.01) after the temporary occlusion of portal vein, while the temporary occlusion of the hepatic artery did not have any significant effect on portal venous circulation. The interaction between hepatic arterial flow and portal venous flow is much in dispute, but, as the data presented here show, there is no doubt that the decrease in portal venous flow immediately gives rise to a significant increase in hepatic artery circulation.

["Serrated" adenoma--a little known type of colorectal tumors]

Eight cases and review of the literature on serrated adenoma of the colon were reported. This distinct entity of colorectal tumors was described in recent years. The tumors contain hyperplastic and adenomatous areas. Their tendency for malignant transformation is similar to pure adenomas to contrary to benign hyperplastic polyps. Three tumors of eight reported cases were pedunculated, while five were sessile. Four patients were operated on because of narrowing of intestinal lumen by the tumors. Malignant transformation of tumors was observed in three cases. Several biopsies were performed before major operations. Histology showed false benign hyperplastic tumors. Importance of multiple tissue sample for histology was emphasised. Electron microscopy showed disturbed differentiation and pathological mucus production of tumor cells.

Blood flow measurement in patients with hepatocellular carcinomas

Since the data regarding the afferent circulation of the liver in patients having primary hepatocellular carcinoma are controversial or missing. Authors carried out the measurement of hepatic arterial and portal venous flow intraoperatively by transit time ultrasonic volume flowmetry. In patients with primary hepatocellular carcinoma the hepatic artery flow increased to 0.55 +/- 0.211 compared with the control value of 0.37 +/- 0.102 1/min (p < 0.01). The portal venous flow decreased from 0.61 +/- 0.212 1/min to 0.47 +/- 1/min (p < 0.01). Due to the opposite changes in the afferent circulation the total hepatic blood flow did not change significantly. The ratio of hepatic arterial flow to portal vein flow elevated to 1.239 +/- 0.246 in patients with hepatocellular carcinoma, which is the double of the basic control value (0.66 +/- 0.259 1/min). After resection this ratio practically did not change. The surgical intervention, that is the resection of the liver did not alter the hepatic artery and portal venous flow significantly, although the total hepatic blood flow has decreased significantly (p < 0.01). The prominent and marked increase in the ratio of hepatic arterial flow may be attributed to the decrease of portal venous flow caused by the primary hepatocellular carcinoma. The decrease of venous flow can be explained most probable by compression and infiltration of the intrahepatic branches of the portal vein. As we pointed out the decrease in portal venous circulation consequently causes increase in hepatic arterial flow.(ABSTRACT TRUNCATED AT 250 WORDS)

Complications following major abdominal surgery in cirrhotic patients

The morbidity and mortality associated with major abdominal surgical interventions in 34 histologically proven cirrhotic patients are analyzed by the authors. The surgical interventions were carried out as urgent, absolute and elective indications. Thirty-seven general and surgical complications were observed following major abdominal surgery in 34 cirrhotics. Seven out of 34 patients died, giving a mortality rate of 21%. Suture-line insufficiency, peritonitis, sepsis and other inflammatory processes turned out to be the most common complications. Statistical analysis showed that the Child criteria, prothrombin level and white blood cell count were useful prognostic factors.

[Severe anaphylactic shock with heart arrest caused by coffee and gum arabic, potentiated by beta-blocking eyedrops]

The case of a male patient who experienced four allergic accidents after drinking coffee is reported. Two serious anaphylactic reactions with cardiac arrest occurred after a continuous treatment with beta-blocking eye drops (timolol) was prescribed. Dual sensitivation to coffee and to the gum arabic coating roasted coffee beans was demonstrated by skin prick tests and by human basophil degranulation tests. Occupational allergy to green coffee has been widely described, but food sensitization to these two allergens has not yet been reported. This case also draws attention to the risk, inherent in beta-blockers, of immuno-allergic reactions. These drugs produce a loss of compensatory cardiovascular mechanisms and make those who take them resistant to the conventional treatment of anaphylactic shocks, which explains the serious accidents that occurred in this patient. The authors stress the usefulness of a thorough investigation for food allergy to a rare allergen in patients with idiopathic anaphylaxis.

Enantioselective and nonenantioselective degradation of organic pollutants in the marine ecosystem

Enantiomeric ratios of 11 chiral environmental pollutants determined in different compartments of the marine ecosystem by chiral capillary gas chromatography and chiral high-performance liquid chromatography allow discrimination between the following processes: enantioselective decomposition of both enantiomers with different velocities by marine microorganisms (alpha-HCH, beta-PCCH, gamma-PCCH); enantioselective decomposition of one enantiomer only by marine microorganisms (DCPP); enantioselective decomposition by enzymatic processes in marine biota (alpha-HCH, beta-PCCH, trans-chlordane, cis-chlordane, octachlordane MC4, octachlordane MC5, octachlordane MC7, oxychlordane, heptachlor epoxide); enantioselective active transport through the "blood-brain barrier" (alpha-HCH); nonenantioselective photochemical degradation (alpha-HCH, beta-PCCH).

[Malignant fibrous hystiocytomas of unusual localizations]

25 cases of malignant fibrous histiocytomas of different localisation were diagnosed in the St. John's Hospital (Budapest, Hungary) in a 10-year period from 1982 to 1992. In the present study ten patients are reported with rare localisation of this tumor caused abdominal complications. Special attention is payed to diagnostic difficulties. The importance of morphological diagnosis is emphasized because modern therapeutic methods favourably influence the prognosis of this tumor.

[Clinical aspects and management of a retroperitoneal abscess]

14 patients with retroperitoneal abscess have been collected by the authors since June 1, 1988. The retroperitoneal abscess of multifactorial origin can be considered as a secondary disease. The physical clinical signs (e.g. psoas rigidity sign, palpable mass, costolumbal sensitivity) play central role in setting up of diagnosis, and these signs were present in more than 75% of the cases. The physical signs generally indicate advanced retroperitoneal abscess, and at the same time the contour of psoas muscle disappears and concavity of lumbal vertebras can be seen on plane abdominal X ray film. The exact diagnosis was achieved in mean 45 days after the on set of complaints, this fact urges, that the up-to-date imaging modalities (US, CT, NMR) should be applied earlier in septic conditions of unknown origin. Retroperitoneal surgical intervention was performed in their patients, in the future the percutaneous drainage procedure has to be considered as first intervention for retroperitoneal abscess. Retroperitoneal abscess secondary to malignant disease has unfavorable prognosis, 2 out of 14 patients with retroperitoneal abscess died, both of them had underlying malignancy.

[Prinzmetal angina pectoris causing diagnostic and therapeutic problems]

A 53 year old patient was hospitalized because of retrosternal oppression which was unrelated to effort and recurred in the early morning hours. An esophageal diverticulum and a hiatal hernia were found. The patient had complaints in spite of medical therapy and an operation was performed because of his oesophageal disorders. After operation the patient had the same pain. A cardiologist was asked, who suggested Prinzmetal variant angina. During arteriography coronary artery disease was found. Coronary bypass surgery was indicated and performed, after that procedure the patient was and remained free of any complaints. This observation reaffirmed Prinzmetal original statement "The key to the diagnosis ... is the taking of a painstaking history".

Intraoperative estimation of liver blood flow in man

The intraoperative measurement of the afferent circulation of the liver, namely the hepatic artery flow and portal venous flow was carried out upon 14 anaesthetized patients having carcinoma of the splanchnic area, mainly in the head of the pancreas, by means of transit time ultrasonic volume flowmeter. The hepatic artery flow, portal venous flow and total hepatic flow were 0.377 +/- 0.10; 0.614 +/- 0.21; 0.992 +/- 0.276 l/min, respectively. The ratio of hepatic arterial flow to portal venous flow was 0.66 +/- 0.259. There was a sharp, significant increase in hepatic arterial flow (29.8 +/- 6.1%, p < 0.01) after the temporary occlusion of portal vein, while the temporary occlusion of hepatic artery did not have any significant effect on portal venous circulation. The interaction between hepatic arterial flow and portal venous flow is a much disputed question, but according to the presented data here, it is unquestionable, that the decrease of portal venous flow immediately results a significant increase in hepatic artery circulation.

[Complications of abdominal surgery in patients with liver cirrhosis]

The morbidity and mortality of major abdominal surgical interventions in 34 histologically proven cirrhotic patients are analysed by the authors. The surgical interventions were carried out by urgent, absolute and elective indications. 37 general and surgical complications could have been observed following the major abdominal surgery of 34 cirrhotics. 7 out of 34 patients died. Suture-line insufficiency, peritonitis, sepsis and other inflammatory processes turned out most frequently among the complications. The Child criteria, the prothrombin level and white blood cell count proved to be useful prognostic factors by statistical analysis.

Foot and ankle disorders resulting from Lyme disease

Ten cases of Lyme disease involving the foot and ankle are reported. Onset of symptoms was months to years before diagnosis. A variety of clinical foot and ankle problems resulted. Careful case histories and serologic testing resulted in proper diagnosis and treatment.

[Acute respiratory distress syndrome in the initial phase of myocardial infarction in adults]

Four patients developed an acute respiratory distress syndrome characterised by clinical and radiological signs of pulmonary oedema, a protein-rich oedema, severe hypoxemia refractory to oxygen therapy, contrasting with normal left ventricular filling pressures and indicating increased permeability of the alveolo-capillary membrane, 24 to 72 hours after the onset of acute myocardial infarction. After having excluded the usual causes of the acute respiratory distress syndrome, the authors suggest that acute myocardial infarction, especially when extensive, may cause a lesion of the alveolo-capillary membrane by an unknown mechanism. Treatment consisted in mechanical ventilation with positive expiratory pressures in 3 cases and with continuous positive pressure during spontaneous respiration in the third patient and in relay with controlled ventilation in the other two. These techniques of ventilation improved the hypoxemia and led to complete cure in all cases without evolution to pulmonary fibrosis. In addition to mechanical ventilation, all patients were given systematic antibiotic therapy because of the possibility of an infectious etiology while waiting for the results of microbiological and serological testing and because of the high risk of superinfection which plays an essential part in the outcome of the condition. The immediate response to treatment was favourable in all cases. One patient died suddenly of cardiogenic shock two weeks after this episode. The other patients are still alive 39, 38 and 20 months after infarction. The importance of the diagnosis of the acute respiratory distress syndrome in the acute phase of myocardial infarction resides in its therapeutic implications which are quite different to those of cardiogenic shock.(ABSTRACT TRUNCATED AT 250 WORDS)